Management of COVID-19 Response in a Secure Forensic Mental Health Setting: Réponse à la gestion de la COVID-19 dans un établissement sécurisé de santé mentale et de psychiatrie légale

OBJECTIVES

The coronavirus disease 2019 (COVID-19) pandemic presents major challenges to places of detention, including secure forensic hospitals. International guidance presents a range of approaches to assist in decreasing the risk of COVID-19 outbreaks as well as responses to manage outbreaks of infection should they occur.

METHODS

We conducted a literature search on pandemic or outbreak management in forensic mental health settings, including gray literature sources, from 2000 to April 2020. We describe the evolution of a COVID-19 outbreak in our own facility, and the design, and staffing of a forensic isolation unit.

RESULTS

We found a range of useful guidance but no published experience of implementing these approaches. We experienced outbreaks of COVID-19 on two secure forensic units with 13 patients and 10 staff becoming positive. One patient died. The outbreaks lasted for 41 days on each unit from declaration to resolution. We describe the approaches taken to reduction of infection risk, social distancing and changes to the care delivery model.

CONCLUSIONS

Forensic secure settings present major challenges as some proposals for pandemic management such as decarceration or early release are not possible, and facilities may present challenges to achieve sustained social distancing. Assertive testing, cohorting, and isolation units are appropriate responses to these challenges.

<p>Epidemiology of <em>Plasmodium falciparum</em> infection and drug resistance markers in Ota Area, Southwestern Nigeria</p>

Purpose: Effective routine monitoring and surveillance of parasite genes is a necessary strategy in the control of parasites’ resistance to antimalarial drugs, according to the WHO’s recommendation. This cross-sectional study therefore aimed at carrying out an epidemiological analysis on malaria incidence in Ado-Odo/Ota, Ogun State.

Patients and methods: Blood and corresponding saliva samples were collected from 1,243 subjects of all ages and sex presenting with fever and a parasitemia level ≥2,000 between September 2016 and March 2018. Samples were collected from selected health facilities in the study area of Ogun state to establish the prevalence of falciparum malaria and determine resistance genes harbored by the parasites. The overall prevalence of falciparum malaria in the study site by microscopic examination was 45.86%. The highest incidence of 57.42% was recorded among male subjects. Point mutations of K76T and N86Y in the Pfcrt and pfmdr-1 genes, as well as non-synonymous mutations in Pfk13 genes, were screened for and sequenced for further analysis.

Results:Pfcrt was detectable in 57.42% of blood and 51.02% of saliva samples, respectively. About 34.78% of the subjects that were confirmed microscopically harbored the Pfmdr-1 mutated gene while 26.67% of the saliva samples revealed Pfmdr-1. Epidemiological studies identified the presence of wild-type Pfk13 genes in 21.84% of blood and 44.44% of saliva samples correspondingly. For each of the genes evaluated, saliva portrayed great diagnostic performance when compared with blood.

Conclusion: Findings from this study have established the prevalence of malaria and the resistance pattern of P. falciparum in the study area. The findings may help in formulating drug policies and suggest the use of saliva as a noninvasive point-of-care method of diagnosing malaria potentially deployable to rural endemic areas.

Time Trends in Homicide and Mental Illness in Ontario from 1987 to 2012: Examining the Effects of Mental Health Service Provision

OBJECTIVE

We examine the association between rates of homicide resulting in a mental health disposition (termed mentally abnormal homicide [MAH]) and homicides without such a disposition, as well as to province-wide psychiatric hospitalisation and incarceration rates.

METHOD

In this population-based study, we investigate all adult homicide perpetrators ( n = 4402) and victims ( n = 3783) in Ontario from 1987 to 2012. We present annual rates of mentally abnormal and non-mentally abnormal homicide and position them against hospitalisation and incarceration rates.

RESULTS

Among the total sample of homicide accused, 3.7% were mentally abnormal. Most (82.5%) had a psychotic disorder at the time of the offense. Contrasted with declining hospitalisation, incarceration, and population homicide rates, the rate of MAH remained constant at an average of .07 perpetrators per 100,000 population. The rate of MAH was not associated with discharges from or average length of stay in psychiatric hospitals (ρ = 0.10; 0.34, P > 0.10), incarceration rates (ρ = 0.16, P = 0.42), or the total homicide rate (ρ = 0.25, P = 0.22). The proportion of MAH perpetrators with a substance use disorder increased modestly over time (β = 0.35, R2 = 0.12, P = 0.08).

CONCLUSIONS

The rate of MAH has not changed appreciably over the past 25 years. Declining psychiatric service utilisation was not associated with the rate of homicide committed by people with mental illness and, secondarily, was not linked to increases in the population homicide or incarceration rates. Substance use has become a more prevalent problem for this population.

Homeopathic prescribing for chronic and acute periodontal conditions in 3 dental practices in the UK

INTRODUCTION

This investigation extends our previous dental data collection pilot study with the following main aims: to gain insight into the periodontal complaints that dentists in the UK treat using individualised homeopathic prescription; to record patient-assessed change in severity of treated complaint (acute or chronic); to determine periodontal pocket depth (PPD).

MATERIALS AND METHODS

Three dentists recorded data systematically at 249 homeopathic appointments in 51 patients over a period of 18 months. A spreadsheet enabled the data collection of the following records: date of appointment; anonymised patient identity; main periodontal problem treated; whether the condition was acute or chronic; patient-assessed clinical outcome on a 7-point Likert scale, ranging from -3 to +3, to compare the first and any subsequent appointments; whether any interventional dental surgery (IDS) had been carried out; clinician-assessed PPD measurements.

RESULTS

At least one follow-up (FU) appointment was reported for each of 46 patients (22 chronic [6 with IDS, 16 without IDS]; 24 acute [10 with IDS, 14 without IDS]). In chronic cases, strongly positive outcomes (score of +2 or +3) were reported by 2 (33.3%) of 6 IDS patients and by 1 (6.3%) of 16 non-IDS patients. In acute cases, strongly positive outcomes were reported by 7 (70%) of 10 IDS patients and by 8 (57.2%) of 14 non-IDS patients (no statistically significant difference between sub-groups). The FU conditions most frequently treated with homeopathy were chronic periodontitis (19 patients) and acute periodontal abscess (11 patients). Analysis of PPD data was not feasible due to the small numbers of patients involved.

CONCLUSION

Limited insight has been gained into the periodontal complaints treated by homeopathy in the UK. Due to small sample size and equivocal results, the interpretation of the patient-reported outcomes data is unclear. Positive findings obtained in the acute treatment setting suggest that this may be a promising area for research in periodontal homeopathy.

Frontal sinus depth at four landmarks in breeds of dog typically affected by sinonasal aspergillosis

The objective of this study was to assess whether the frontal sinuses in dogs with aspergillosis and of breeds typically affected by this condition were deeper at a more caudal location. CT scans of the head performed at the Small Animal Teaching Hospital, University of Liverpool, between April 2007 and March 2009 for dogs diagnosed with aspergillosis (group 1) and unaffected dogs of similar breeds (group 2) were selected for study. Sinus depth was measured at four standardised locations from reconstructed images of these CT scans. Data were compared for differences in sinus depth between groups and between landmarks. No significant difference was found between measurements within individual dogs or for each of the various landmarks between groups. Difference in depth of the sinuses between landmarks was significant (P<0.001). Sinus depth was significantly greater at the more caudal landmarks and was shallowest at the previously recommended landmark for sinus entry. In 54 per cent of dogs, the frontal sinus depth measured less than or equal to 2 cm at one or more of the landmarks. Sinus entry at the deepest point will reduce the risk of accidentally damaging underlying structures. This may be approximately 1 cm caudal, in breeds of dog that typically develop aspergillosis, to a previously suggested landmark.

High-throughput genotyping of hop (Humulus lupulus L.) utilising diversity arrays technology (DArT)

Implementation of molecular methods in hop (Humulus lupulus L.) breeding is dependent on the availability of sizeable numbers of polymorphic markers and a comprehensive understanding of genetic variation. However, use of molecular marker technology is limited due to expense, time inefficiency, laborious methodology and dependence on DNA sequence information. Diversity arrays technology (DArT) is a high-throughput cost-effective method for the discovery of large numbers of quality polymorphic markers without reliance on DNA sequence information. This study is the first to utilise DArT for hop genotyping, identifying 730 polymorphic markers from 92 hop accessions. The marker quality was high and similar to the quality of DArT markers previously generated for other species; although percentage polymorphism and polymorphism information content (PIC) were lower than in previous studies deploying other marker systems in hop. Genetic relationships in hop illustrated by DArT in this study coincide with knowledge generated using alternate methods. Several statistical analyses separated the hop accessions into genetically differentiated North American and European groupings, with hybrids between the two groups clearly distinguishable. Levels of genetic diversity were similar in the North American and European groups, but higher in the hybrid group. The markers produced from this time and cost-efficient genotyping tool will be a valuable resource for numerous applications in hop breeding and genetics studies, such as mapping, marker-assisted selection, genetic identity testing, guidance in the maintenance of genetic diversity and the directed breeding of superior cultivars.

Molecular phylogeny of wild Hops, Humulus lupulus L

We have analysed wild hops collected widely from the Northern Hemisphere, assessing the genetic diversity and the geographical distribution of haplotypes, to investigate the evolution and phylogeny of hops, Humulus lupulus. The haplotypes were characterized by the nuclear ribosomal DNA spacer region (length and DNA sequence) and chloroplast DNA noncoding regions (DNA sequences). The results indicated that primary divergence into European (including Caucasus and Altai hops), and Asian-North American types, was 1.05+/-0.28 to 1.27+/-0.30 million years ago. Although an Eastern boundary for European nuclear haplotype distribution was unclear due to the ambiguous origin of Northern Chinese samples, the European hop group showed a wide geographical distribution across Eurasia from the Altai region to Portugal. The low genetic variation in this group suggested rapid and recent expansion. The North American hop group showed high diversity, and is considered to include hops that have migrated from Asia. Japanese and Chinese hops were identified as genetically distinct. This study has shown that wild hops in each growing region are genetically differentiated with considerable genetic diversity. It gives insights into the evolution and domestication of hops that are discussed.

Sexual development and sex chromosomes in hop

The stages of floral development in staminate and pistillate plants of hop (Humulus lupulus) were defined using scanning electron microscopy and light microscopy. Vegetative meristems of male and female plants are morphologically indistinguishable. On transition to the reproductive phase, inflorescence apices reduce greatly in size and striking developmental sex differences become apparent. The first sex-specific differences occur extremely early in floral ontogeny. Both male and female plants initiate inflorescence meristems at each leaf node, each meristem being enclosed within a bract. Male secondary inflorescence meristems give rise to clusters of asynchronously developing flowers. Female inflorescence meristems produce flowers arranged in 'cones'. Each male floral meristem initiates a whorl of five sepal primordia, followed by an inner whorl of five stamen primordia. There is no sign of carpel development at any stage. In females, two carpel primordia are initiated, surrounded at their base by a vestigial perianth whorl. No stamen development is observed. Several monoecious lines carry bisexual flowers, either within cymose panicles or within the basal bracts of terminal female inflorescences. Bisexual flowers usually possess perianth, stamen and carpel whorls. The central whorls are often highly variable, and range from a pair of stigmas fused to a thin central filament to a well developed gynoecium. Chimaeric central whorls consisting of fused staminoid-carpelloid structures also occur. Sex differences in unisexual hop flowers are determined at an extremely early stage in ontogeny. The inappropriate set of sex organs is suppressed before it becomes visible or, more probably, it is not initiated at all. Genes directing the development of sex are likely to act at an extremely early stage, well in advance of floral organogenesis. The sex chromosomes of dioecious hop plants are described, as well as the chromosome constitutions of monoecious plants and those carrying bisexual flowers.

Evaluation of predictive factors for neurocognitive dysfunction in patients with inactive systemic lupus erythematosus

OBJECTIVE

To determine predictive factors associated with the cognitive dysfunction in patients with inactive systemic lupus erythematosus (SLE).

METHODS

Consecutive patients followed at the Lupus Clinic with inactive SLE (SLE Disease Activity Index, SLEDAI, = 0) underwent a battery of neuropsychological tests; Beck Depression Inventory and psychiatric assessment were also performed. Neurocognitive dysfunction was defined as 3 abnormal scores. Data were analyzed using chi-square tests, ANOVA tests, and logistic regression.

RESULTS

Twenty-five of the 58 patients with SLE (43%) versus 9 of 47 healthy controls (19%) demonstrated neurocognitive dysfunction (p < 0.01). Neurocognitive dysfunction was not associated with depression or a psychiatric diagnosis, use of steroids, or previous or current evidence for fibromyalgia. SLEDAI > 10 at first presentation to the Lupus Clinic and previous vasculitis were associated with neurocognitive dysfunction, but previous central nervous system disease, renal disease, renal damage, or atherosclerotic complications were not. Neurophysiologic studies at the time of the assessment were not predictive of neurocognitive dysfunction.

CONCLUSION

Patients with inactive SLE demonstrate neurocognitive dysfunction. This is associated with more disease activity at presentation, but is not associated with specific organ involvement or organ damage.

Painless intravenous catheterization by intradermal jet injection of lidocaine: a randomized trial

STUDY OBJECTIVE

To compare efficacy and cost of lidocaine cutaneous anesthesia by two jet injectors to routine needle infiltration for pain relief of intravenous (i.v.) catheterization, hypothesizing that jet injection of lidocaine is less painful than its needle infiltration.

DESIGN

Randomized, prospective, controlled trial.

SETTING

University hospital outpatient surgical unit.

PARTICIPANTS

75 surgical patients ASA I and II.

INTERVENTIONS

Three groups of 25 patients each were given intradermal lidocaine anesthesia via conventional 25-gauge needle/syringe; by MedEJet or Biojector jet injector prior to IV catheterization with an 18-gauge Jelco catheter.

MEASUREMENTS AND MAIN RESULTS

Visual analogue pain scores (VAS) (0 = no pain, 10 = intolerable pain) and subjective pain intensity scores (PIS) (0 = not painful, 4 = intolerable pain) at lidocaine application and at i.v. catheterization, were recorded. Cost assessment of each method was made. At local anesthetic application, no pain by proportion of VAS = 0 with MedEJet: 25/25 (confidence interval [CI]: 0.868, 0.999) and Biojector: 24/25 (CI 0.804, 0.991) was noted, but-22 of 25 patients experienced pain with needle administration: (with VAS = 0; 3/25 [CI: 0.044, 0.302]) (posterior probability [PP] > 0.999). The corresponding VAS scores (means +/- SD) were 0.00 +/- 0.00, 0.04 +/- 0.20, and 2.4 +/- 2.23 (p < 0.001). No pain by proportion of PIS = 0 with MedEJet: 25/25 (CI: 0.868, 0.999 and Biojector: 23/25 (0.749, 0.976) was noted, but pain in 20/25 was felt with the needle: 5/25 (CI: 0.090, 0.394) (PP > 0.999). The corresponding PIS scores were 0.00 +/- 0.00, 0.16 +/- 0.55, and 1.24 +/- 1.00 (p < 0.001). At i.v. catheterization, no pain by proportion of VAS = 0 with MedEJet: 22/25 (CI: 0.698, 0.956) or Biojector: 21/25 (CI: 0.651, 0.934) was noted; but pain in 19/25 with needle administration was experienced: 6/25 (CI: 0.116, 0.436) (PP > 0.999). The corresponding scores were 0.12 +/- 0.33, 0.44 +/- 0.20, and 1.64 +/- 1.50 (p < 0.001). No pain by proportion of PIS = 0 with MedEJet: 24/25 (CI: 0.804, 0.991) or Biojector: 24/25 (CI: 0.804, 0.991) was noted, but pain was apparent in 12/25 with needle administration: 13/25 (CI: 0.334, 0.701) (PP > 0.999). The corresponding scores were 0.00 +/- 0.00, 0.00 +/- 0.00, and 0.76 +/- 0.88 (p < 0.001). Cost per application: MedEJet = $0.13; needle/syringe = $0.50; Biojector = $0.94.

CONCLUSIONS

Almost completely painless i.v. catheterization was carried out by jet injection of lidocaine, but needle infiltration produced discomfort or pain and did not significantly reduce discomfort or pain at the i.v. needle insertion.

Placebo-controlled studies in schizophrenia--ethical and scientific perspectives: an overview of conference proceedings

Much controversy has surrounded the issue of whether clinical trials of new antipsychotic medications for the treatment of schizophrenia ought to include a placebo control group. On 18 September 1997, the authors co-chaired a symposium at the University of Toronto devoted to elucidating the issues relevant to this debate. Speakers with expertise in the areas of schizophrenia research, clinical trials methodology, medical ethics and informed consent presented their perspectives. This paper aims to summarize the major scientific and ethical issues raised during the symposium.

V. A new route, jet injection of lidocaine for skin wheal for painless intravenous catheterization

OBJECTIVE

The objective of this study was to compare the efficacy of intradermal lidocaine anesthesia by two jet injectors to the routine needle infiltration and to the topical EMLA cream.

SUBJECTS AND METHODS

In a randomized, prospective, controlled trial, 100 consenting surgicenter patients in a university hospital setting were divided into four groups (n = 25, each); intradermal lidocaine anesthesia was given either by the conventional 25 g needle/syringe or the Med-E-Jet or Biojector injector or EMLA cream was applied on the skin. Visual analogue pain scores (VAS) or verbal pain intensity scores (PIS) were reported by the patients at lidocaine application and i.v. catheterization. Cost was also assessed.

RESULTS

At lidocaine application, no pain was reported, since proportions of VAS = 0 were 25/25 (CI: 0.868, 0.999) with Med-E-Jet; 24/25 (0.804, 0.991) with Biojector; 25/25 (0.868, 0.999) with EMLA; in contrast to pain, 3/25 (0.044, 0.302) with the needle (PP > 0.999). The VAS scores (mean +/- SD) were 0.00 +/- 0.00, 0.04 +/- 0.20, 0.00 +/- 0.00, and 2.4 +/- 2.2 respectively (p < 0.00 1). No pain was reported by proportions of PIS = 0 with Med-E-Jet: 25/25 (CI: 0.868, 0.999); with Biojector: 23/25 (0.749, 0.976); EMLA 25/25 (0,868, 0.999); but pain with the needle: 5/25 (0.090, 0.394) (PP > 0.999). The mean +/- SD PIS scores were 0.00 +/- 0.00, 0.16 +/- 0.55, 0.00 +/- 0.00, and 1.24 +/- 1.00, respectively (p < 0.001). At i.v. catheterization, the proportions of VAS = 0 scores were 22/25 with Med-E-Jet (0.698, 0.956); 21/25 (0.651, 0.934) with Biojector; but some pain with needle: 6/25 (0.116, 0.436) (PP > 0.999). The mean +/- SD VAS scores were: 0.12 +/- 0.33, 0.44 +/- 0.20, and 1.64 +/- 1.50, respectively (p < 0.001). No pain was reported by PIS = 0 scores in 24/25 (0.804, 0.991) with Med-E-Jet; 24/25 (0.804, 0.991) with the Biojector; but pain by zero PIS scores 13/25 (0.334, 0.703) in half of the patients in the needle group (PP > 0.999). The mean +/- SD scores were 0.00 +/- 0.00, 0.00 +/- 0.00, and 0.76 +/- 0.88, respectively (p < 0.001). The EMLA cream was not evaluated because of inadequate duration of application prior to anesthetic induction. Cost/application were: Med-E-Jet = $ 0.13; needle = $ 0.50; Biojector = $ 0.94 and EMLA = $ 3.76.

CONCLUSION

Almost completely painless i.v. catheterization by jet injection of lidocaine was accomplished, while needle infiltration produced pain/discomfort and did not significantly reduce it at the i.v. needle insertion.

The parents' group: a multidisciplinary project

A regular group to support young mothers is an important resource, enabling them to share common concerns, write Wendy Birkinshaw, Pauline Darby and Susan Strasser. A multi-disciplinary approach, with ongoing management supervision, brings a broader perspective and reassurance through difficult periods.

Autoradiographic analysis of regional brain glucose utilization in chronically monitored unanesthetized fetal sheep

This communication describes the successful qualitative differential labeling, utilizing 2-[14C]deoxyglucose, of brain structures in a healthy, non-breathing chronic fetal sheep preparation in late gestation. This preliminary result suggests that during quiet sleep (non-breathing state) the fetal sheep may be processing a variety of sensory input from the auditory, vestibular, and olfactory systems at a thalamic, limbic system level.